Akhil Chhatre

Bilateral Intra-Articular Radiofrequency Ablation for Cervicogenic Headache

Introduction. Cervicogenic headache is characterized by unilateral neck or face pain referred from various structures such as the cervical joints and intervertebral disks. A recent study of patients with cervical pain showed significant pain relief after cervical medial branch neurotomy but excluded patients with C1-2 joint pain. It remains unclear whether targeting this joint has potential for symptomatic relief. To address this issue, we present a case report of C1-2 joint ablation with positive outcomes. Case Presentation. A 27-year-old female presented with worsening cervicogenic headache. Her pain was 9/10 by visual analog scale (VAS) and described as cramping and aching. Pain was localized suboccipitally with radiation to her jaw and posterior neck, worse on the right. Associated symptoms included clicking of her temporomandibular joint, neck stiffness, bilateral headaches with periorbital pain, numbness, and tingling. History, physical exam, and diagnostic studies indicated localization to the C1-2 joint with 80% decrease in pain after C1-2 diagnostic blocks. She underwent bilateral intra-articular radiofrequency ablation of the C1-C2 joint. Follow-up at 2, 4, 8, and 12 weeks showed improved function and pain relief with peak results at 12 weeks. Conclusion. Clinicians may consider C1-C2 joint ablation as a viable long-term treatment option for cervicogenic headaches.

Persistent Singultus Associated with Lumbar Epidural Steroid Injections in a Septuagenarian: A Case Report and Review

Singultus are rare but notable adverse effect of epidural steroid injections (ESIs). To date, reports of persistent hiccups associated with ESIs have been reported mostly in adults aged 65 years or older. We present the first case of persistent hiccups in a septuagenarian who underwent repeated transforaminal ESIs for chronic lumbar radiculopathy. Under fluoroscopic guidance, 1.5 mL of 1% lidocaine (preservative free) and 0.8 mL of dexamethasone solution (10 mg/mL) was injected into the bilateral L4–L5 neural foramen and epidural space. After the first epidural injection, episodes of singultus occurred at a frequency of 5 to 7 episodes per minute and lasted for 36 hours. One month later, he was treated with the second epidural injection after which he immediately developed singultus, occurring at 2- to 3-hour intervals. Interventions for the singultus included drinking small sips of water, vagal maneuvers, and oropharyngeal stimulation with ice chips. The singultus eventually resolved without medical intervention within 5 days of onset. A major take-home point is that preprocedure informed consent should include singultus as one of the potential adverse effects of ESIs. Increased awareness and appropriate planning may help curb the incidence of adverse outcomes in older adults undergoing ESI.

Poster 374 Sexual Dysfunction After Sacroiliac Joint Radiofrequency Denervation: A Case Report.

Disclosures: Ada Lyn Yao: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This is a case of a 47-year-old patient who underwent radiofrequency denervation in bilateral sacroiliac joints through an S1, S2, S3 lateral branch and L5 dorsal rami radiofrequency neurotomy. A few days after the procedure, the patient noticed difficulty experiencing an orgasm. At that time, there was no note of increased/worsening pain, dyspareunia, bowel incontinence, bladder incontinence, development of constipation or rectal pain. There were no new medications or any recent changes in her medication dosages and there were none identified that could cause anorgasmia. The patient did not seek medical management for the sexual dysfunction. No specific intervention was undertaken for it, and by three to four weeks after the nerve ablation, there was observed symptom improvement and by six weeks post-procedure, this had resolved completely. Setting: Outpatient Pain Clinic. Results: At week six post-ablation, the patient no longer experienced anorgasmia, implying the symptom resolved on its own. Discussion: To our knowledge, past research has not reported anorgasmia as a complication following sacroiliac joint radiofrequency ablation for sacroiliac joint pain. The S2-S4 nerve roots serve the pudendal nerve, which serves the dorsal nerve of the clitoris, the nerve responsible for orgasm. With S2 and S3 roots among those targeted for the procedure, and S2-S4 nerve roots serving the pudendal nerve, shocking S2 and S3 may have temporarily affected innervation of the clitoris. Conclusions: Sexual dysfunction, specifically anorgasmia, may be a complication of sacroiliac joint radiofrequency ablation given common innervation of the joint’s pain generators and the pudendal nerve. Level of Evidence: Level V

Poster 374 Discitis Secondary to Intravenous Injection of Crushed Oxycodone: A Case Report

were treated with fluoroscopically guided lumbar TFESI. Interventions: Patients were administered 80mg DepoMedrol and 1mL of 0.25% bupivicaine at two separate levels and completed the follow-up assessment. Main Outcome Measures: Patient-reported concordant or discordant provocation was assessed during each injection. The primary outcome measure was self-rated percentage of pain reduction from baseline at follow up. Secondary outcome measures were measurements in activity level and daily analgesic consumption. Results: 100% incidence of injection related provocation which was further subclassified as concordant (66%) or discordant (34%). At 2 week post injection follow up, the discordant group achieved a statistically greater decrease in self-reported pain (76%) compared to the concordant group (58%; t 2.1; df (45); P .04). There were no statistically significant differences between concordant and discordant groups with respect to improvements in functional outcome and decreased use of daily oral pain medications. Conclusions: The incidence of provocation was 100%. Both groups achieved significant pain reduction. Concordant provocation did not predict better outcomes. The discordant group had significantly higher self-reported pain reduction in comparison to the concordant group without concomitant functional improvements and reduction in medications. Concordant provocation is not a predictor of response to TFESI.

Poster 245 Hip and Pelvic Pathology Presenting as Lumbago: A Retrospective Chart Review of Spine Center Referrals

variables were compared for the 2 groups. Results: Both PRP and ESWT groups show decreased VAS score and DASH score. PRP group shows more effective in the functions after treatments (P .05). Successful treatment was defined as more than a 25% reduction in VAS or DASH score 6 months after treatments. The results showed that, according to the VAS, 93.2% (68/73 subjects) in the PRP group and 92.6% (50/54 subjects) in the ESWT group were successful. According to the DASH scores, 87.7% (64/73 subjects) in the PRP group and 96.3% 52/54 subjects) in the ESWT group were successful. Conclusions: PRP and ESWT groups for subjects with chronic lateral epicondylitis show reducing pain. PRP group shows more effective in the function. But successful treatment rate is similar. Future studies for treatments of lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible benefits as well as comparison with each other.

Poster 288 Brown-Séquard Presentation of Transverse Myelitis After Chemotherapy

esthesia of his feet. He had trace ankle jerks but hyperreflexia at the knees and biceps. Setting: Inpatient. Results or Clinical Course: A lumbar tap was revealing for elevated proteins and EDS showed evidence for a peripheral demyelinating sensorimotor polyneuropathy as well as a right ulnar nerve conduction block at the elbow. He was diagnosed with GuillainBarre syndrome (GBS), treated with intravenous immunoglobulin, and transferred to the acute inpatient rehab service. Repeat exams throughout his rehab course demonstrated persistent hyperrelexia. He initially required minimal assistance for most functional measures, but was discharged home at a modified independent level. Discussion: GBS is now thought of as a disease spectrum with variable clinical findings and features. This patient’s presentation of bilateral UN, normoreflexia and descending symptoms obscured the diagnosis of a rare hyperreflexic variant of GBS which has only recently been reported. The underlying process for hyperreflexia in this variant is unknown and it has more often been associated with EDS findings of axonal loss rather than a primarily demyelinating process as in this patient. Conclusions: Physicians should be aware of the variable presentation and clinical symptomatology of the GBS disease spectrum with specific recognition that preservation of reflexes or hyperreflexia does not exclude the diagnosis.

Poster 129 An Unusual Cause of Right Upper Extremity Weakness and Shoulder Girdle Atrophy: A Case Report

Disclosures: M. M. Ibrahim, No Disclosures. Case Description: Three patients underwent lumbar laminectomy and fusion. In each case, the patients were placed prone with the arms abducted and extended for a prolonged period of time. Immediately postoperatively, all 3 patients were found to have varying degrees of motor and sensory deficits in the upper extremities. Setting: Inpatient rehabilitation center. Results or Clinical Course: EMG was performed in all 3 cases. Patients were found to have a medial cord plexopathy, a musculocutaneous neuropathy, and a bilateral upper and middle trunk plexopathy, respectively. Discussion: Brachial plexopathies have been described in the literature for over a century. Most present as a painless weakness in the upper brachial plexus distribution. Over the past decade, the number of spinal surgeries has markedly increased, leading to an increase in the frequency of brachial plexopathies. The brachial plexus is vulnerable due to its long superficial course and contact with free moving bony structures, which makes it prone to stretch and compression from malpositioning. With general anesthesia abolishing patient awareness and muscle tone, the risk for injury is even greater. Uribe et al. revealed that 17 patients out of 517 experienced postoperative brachial plexopathy after being in the prone position, with varying neurological manifestations. Specifically, the prone position with arms abducted greater than 90 degrees was most often associated with postoperative brachial plexus lesions. Prognosis appears positive, with improvement of symptoms occurring within weeks to months. Monitoring somatosensory evoked potentials, motor evoked potentials, and EMG during surgery has been shown to be a beneficial modality in detecting nerve injury to prevent postoperative deficits. Conclusions: It is important to be aware of the possibility of brachial plexus lesions in the setting of prolonged surgery to facilitate preemptive management, including repositioning. The use of intraoperative electrophysiological monitoring can also help reduce the incidence of injury. In addition, inpatient rehabilitation can help further improve function.

Poster 226 Hip and Pelvic Pathology Mimicking Lumbago: A Retrospective Chart Review of Spine Center Referrals

Disclosures: S. G. Chung, none. Objective: To identify which structure under ultrasonographic view is the true coracohumeral ligament (CHL) by correlating sonographic versus dissectional anatomy. Design: Prospective laboratory investigation. Setting: Anatomy laboratory at a medical school. Participants: 10 fresh frozen cadaveric shoulders. Interventions: With ultrasonography, 3 structures, which originated from the coracoid process inserting into the rotator interval, were identified as possible CHLs: an echogenic band from the lateral tip of the coracoid process to the rotator interval, a fibrillar structure that originated on the upper surface of the coracoid process, and a hypoechoic structure immediately under the coracoacromial ligament that originated from the mid portion of the coracoid process. Under ultrasound guidance, 3 different colored rubber markers were inserted into each of the structures through a 16-gauge intravenous catheter. Main Outcome Measures: Anatomical dissection was done to find which structure with a specific colored marker was the real CHL. Results: The lateral tip of the coracoid process to the rotator interval was identified to be loose fascial connective tissues covering the subscapularis tendon. The upper surface of the coracoid process was found to be the pectoralis minor tendon overriding the coracoid process. mid portion of the coracoid process was the true CHL, which was visualized more prominently by rotating the shoulder externally. Conclusions: CHL was identified as the structure that originated from the mid portion of the coracoids process deeper to the coracoacromial ligament, with slightly low echogenicity. It should be noted that the adjacent connective tissues could be easily confused with CHL.

Poster 142: Suprascapular Nerve Lesions: Underrecognized But Common Cause of Intractable Shoulder Pain. A Retrospective Analysis

on MRI. Among these 63 patients, 13 (20.6%) have spine osteoporosis and 14 (22.2%) femoral osteoporosis, 26 (41.2%) have spine osteopenia and 30 (47.6%) have femoral osteopenia (P .98). Conclusions: There were not any meaningful correlation between LSS and BMD but about a quarter of LSS patients had spinal osteoporosis and more than 70% of them had abnormal spinal BMD. So in the conservative management of LSS patients, osteoporosis exercise contraindication (flexion and hyperextension) should be considered, however, simultaneous therapy of LSS and osteoporosis in these patients may have more benefits, which is worth evaluating in the future studies.